Use Orders to Track Measures for Mandates

Whether you are tracking something for PCMH, Meaningful Use, or another program, you can use an order in PCC EHR to record medical information.

Orders in PCC EHR include medical procedures, screenings, labs, referrals and any other work done on behalf of a patient. By creating the right kind of order, adding the correct SNOMED-CT codes and LOINC tests to your orders, and configuring your protocols so the orders appear on chart notes, you can make it easy for your clinicians to meet the requirements of any CQM or other mandate rule.

In the examples below, we configure PCC EHR to meet the requirements of NQF 0418: Depression Screening, a Clinical Quality Measure used for PCMH and other mandate programs. For more details about CQM requirements, read How to Chart for Each Clinical Quality Measure.

Create Your Practice’s Orders (and Add Tracking Codes)

For tracking data for any kind of measure, you’ll need a screening, medical procedure, or some other kind of order. Follow the steps below to see how to create (or edit) an order and add required tracking information for a CQM, Meaningful Use Measure, or other mandate.

Open the Protocol Configuration Tool

Click on the Tools menu and select Protocol Configuration.

Open the Component Builder

Click Component Builder on the Protocol Configuration tool window.

Open the Appropriate Orders Component

Double-click on one of your Orders component to add or edit an orders.

Your orders components includes Screening Orders, Medical Procedure Orders, and so forth. They all end with the word “Orders” so they are easier to find.

Edit or Add an Orders

Your practice can have one or more orders that meet the same mandate. For example, for depression screening you might have a different order for a PHQ-9 screening or for other types of depression screening and followup. Click “Add” to create a new order, or double-click on an existing order to make changes.

Configure Basic Order Details

Review the order name and set any other configurable options. For example, you may want certain orders to be private by default, in which case you would deselect the “Include on Patient Reports” option.

Review and Add Tests (LOINC Codes)

Many measures are tracked by the use of a specific, standardized test. Search and add the appropriate test that you perform, and adjust test options.

Tests are identified with a unique LOINC code.

What Tests Should I Add?: The specific test you should add depend on what your practice performs and on the requirements of the mandate you wish to track. For example, for an initial depression screening, you might add 73831-0, “Adolescent depression screening assessment” or 73832-8, “Adult depression screening assessment” for an order for patients 18 years or older. The tests should have a Negative/Positive result. You can also add more than one test to a single order. For example, if you perform a PHQ-9 at each visit, you might first add the “Adolescent depression screening assessment” test, which is used by the clinical quality measure, and then also add the “Patient Health Questionnaire 9 item (PHQ-9) total score” test in order to record the patient’s numerical result.

Review or Add SNOMED-CT Procedure Codes

Many measures are tracked by the use of specific SNOMED-CT Procedure codes. For example, when a patient has a positive result on a depression screening, your practice might perform a suicide risk assessment screening order. That order is tracked with SNOMED-CT.

Edit the relevant Orders component and order, and then add any appropriate SNOMED-CT Procedure codes.

For example, for a suicide risk assessment screening order, you should add 225337009, “Suicide risk assessment (procedure)” to the order. You could also add codes to followup orders, such as Completion of a Mental Health Crisis Plan, Coping Support Management, or other mental health evaluation or treatment.

Some measures, such as the depression CQM, track referrals. Referrals are also tracked with Referral Orders component orders and a SNOMED-CT Procedure description.

For example, you may have referrals for an initial psychiatric evaluation or a specific depression referral.

For information on which SNOMED-CT descriptions to use for each type of order, read How to Chart for Each Clinical Quality Measure.

Repeat for Other Orders that Meet the Same Measure

Your practice may have more than one order that meets the same measure. Click “Add” to create new orders, or double-click on existing orders to make changes. Repeat the steps above to configure the order, and add the appropriate LOINC tests or SNOMED-CT description.

Add Orders to Your Custom Chart Notes

After you make changes to the various orders your practice uses, you can add them to chart notes to make them easier to order. Your clinicians will then see the “Depression Screening” order, for example, on every chart note.

Open the Protocol Configuration Tool

Click on the Tools menu and select Protocol Configuration.

Open the Protocol Builder

Click Protocol Builder on the Protocol Configuration tool window.

Edit a Chart Note Protocol

From the list of Chart Note Protocols, select the first one that could be used for a patient that the measure intended to track. For the Depression example, find the first chart note protocol that would be used for a patient aged 12 years or older. Double-click to edit it.

Edit (or Add) the Orders Component

From the list of components that appear in this chart note protocol, find the relevant orders component (Medical Procedure Orders, Screening Orders, Referral Orders, etc.) and double-click to edit it. Or, click “Add” and select the component to add it to the protocol.

Add the Specific Orders

Click “Add Items” and select the appropriate orders that you wish to track during that type of visit. For example, select the Depression Screening and any other appropriate screening orders to the component in order to track your depression screening rate.

Repeat For Referrals or Other Orders

Optionally, add other screenings, referrals, or other orders. You might also want to add orders that could result from a positive screening, for example.

Repeat For Each Chart Note

You should repeat the above steps for every chart note, adding appropriate orders that you wish to track during the related visit.

Chart the Visit

After you have completed the above configuration, your practice’s clinicians can track the completion of a screening, medical procedure, or other order with a single click.

Optionally, the clinician can assign the order to another clinician, or complete the screening immediately. If the screening is refused, they can select “Refused”. If the screening is contraindicated, they can select “Contraindicated” and enter an appropriate contraindicated diagnosis in the Diagnoses component on the chart note.

When the screening is complete, they can enter a result in the order.

Unless refused or contraindicated, a positive or negative result is often required to track a measure. The result interpretation, in the Interpretation field, is not required for Clinical Quality Measures, though your practice may configure an order to require it.

If a test result is positive, record whatever additional care follows.

For example, you may prescribe appropriate medication, order a Suicide Risk Assessment or order a referral.

Enter results and take any other appropriate followup steps.

Achieve One-Click Reporting By Removing the Default Task

By default, orders have a single incomplete task. If you clinicians remove that task, they can trigger the order (and track data for the measure) with a single click.

First, click Order and then Edit the order.


Next, blank out the default task on the order and click “Save”.


For that clinician, there will no longer be a task that needs completion for the order to be tracked.

Remember to Bill the Visit

When the clinician is finished charting, they should click “Bill” and select an appropriate visit encounter code. In addition to billing, the visit encounter code is used to track data for Clinical Quality Measures and many other reporting features in PCC EHR.

  • Last modified: December 18, 2017